Advances in the Evaluation and Management of Minimal Hepatic Encephalopathy

Abstract

Minimal hepatic encephalopathy (MHE) is a neurocognitive disorder that affects up to 80% of cirrhotic patients. Similar to overt hepatic encephalopathy, ammonia and oxidative stress play key roles in the pathogenesis of MHE. However, MHE is characterized by subtle deficits and psychomotor abnormalities that can only be elicited by specialized psychometric tests. Although no gold standard exists for the diagnosis, MHE remains an important entity for clinicians to recognize because of its negative impact on a patient's health-related quality of life and association with driving impairment and vehicle accidents. MHE has also been associated with an increased rate in the development of overt hepatic encephalopathy and increased mortality; therefore, identification and treatment should not be delayed. Treatment to date has been focused on reducing serum ammonia levels with agents such as lactulose, probiotics, and synbiotics. MHE is a real and growing problem that is epidemic in cirrhosis, and increasing awareness of this condition is necessary for adequate management of these patients.

The Gut Microbiome and the Brain

“…75 It is characterized by subtle intellectual deficits and psychomotor abnormalities that have a significant negative impact on health-related quality of life, impair motor vehicle operation, and increase the incidence of vehicular accidents. 76 Failure to diagnose MHE in apparently ''normal'' patients with chronic liver disease is considered a medical error. 77 Cognitive dysfunction in patients with cirrhosis is associated with altered composition of the gut microbiome, which differs between cirrhotics with or without HE.…”

Cognitive dysfunction, falls and helicobacter pylori in cirrhosis

“…2,10 This finding could help to establish measures to prevent falls and fractures and their consequences in this population. 1,9 When considering the mechanisms involved in the risk of falling, we found no correlation between the severity of PHES impairment and predisposition to falling.…”

A look at the hepatic encephalopathy in cirrhosis

“…In una minoranza di casi non vi è evidenza di fattori precipitanti e i responsabili dell'insorgenza di EE possono essere il deterioramento Figura 2. Possibile approccio diagnostico al paziente cirrotico con sospetta EE [31,55,60,75] CHESS = Clinical Hepatic Encephalopathy Staging Scale; EE = encefalopatia epatica; HESA = Hepatic Encephalopathy Scaling Algorithm; PHES = Psychometric Hepatic Encephalopathy Score della funzione epatica (Acute-on-Chronic Liver Failure) [64] o la presenza di ampi circoli collaterali portosistemici [12]. Inoltre, recentemente, è stato identificato un polimorfismo del gene che codifica per l' enzima glutaminasi in grado di predisporre il soggetto allo sviluppo di EE [65].…”

“…Nonostante i molteplici strumenti disponibili, a causa della mancanza di analisi di costo-beneficio esaurienti riguardo diagnosi e terapia dell' EE Covert, la sua ricerca e il trattamento non vengono ancora impiegati in tutti i pazienti con cirrosi epatica e vengono considerati caso per caso. Un approccio razionale potrebbe essere quello di ricercare elettivamente la presenza di EE Covert in pazienti che svolgono attività a rischio (ad esempio guida di veicoli), lamentano deficit cognitivi o peggioramento della qualità di vita [31,75] (Figura 2). Ulteriori studi sono necessari per la definizione di criteri standardizzati per la diagnosi di EE Covert e ulteriori analisi di costo-beneficio saranno di fondamentale importanza affinchè diagnosi e terapia possano essere considerate in tutti i pazienti cirrotici.…”